Edward P. Sloan, MD, MPH, FACEP Emergency Department Neurological Patient Emergencies: Optimizing...

Edward P. Sloan, MD, MPH, FACEP

Emergency Department Emergency Department Neurological Patient Neurological Patient

Emergencies: Emergencies: Optimizing Patient Outcomes, Optimizing Patient Outcomes, Minimizing Medical Legal RiskMinimizing Medical Legal Risk


A Focus on Acute Ischemic A Focus on Acute Ischemic Stroke Patient Care in the EDStroke Patient Care in the ED


2008 EMA Advanced Emergency & Acute Care

Medicine Conference

Atlantic City, NJAtlantic City, NJSeptember 15, 2008September 15, 2008


Edward P. Sloan, MD, MPH FACEP

Professor

Department of Emergency MedicineUniversity of Illinois College of Medicine

Chicago, IL


Attending PhysicianEmergency Medicine

University of Illinois Hospital

Chicago, IL


DisclosuresDisclosures• FERNE Chairman and PresidentFERNE Chairman and President• Speakers bureau for The Medicine Speakers bureau for The Medicine

Company Company • No grant support for this programNo grant support for this program


www.ferne.orgwww.ferne.org


Ischemic Stroke Patient Ischemic Stroke Patient Case PresentationCase Presentation


Clinical HistoryClinical History A 62 year old female acutely developed A 62 year old female acutely developed

aphasia and right sided weakness while aphasia and right sided weakness while in a store. The store clerk immediately in a store. The store clerk immediately called 911. Paramedics on the scene called 911. Paramedics on the scene within 9 minutes, at 6:43 pm. She arrived within 9 minutes, at 6:43 pm. She arrived in the ED at 7:05 pm… completed her in the ED at 7:05 pm… completed her head CT at 7:25 pm… and a neurology head CT at 7:25 pm… and a neurology consult was obtained at 7:35 pm consult was obtained at 7:35 pm (approximately one hour after the onset (approximately one hour after the onset of her symptoms).of her symptoms).


ED Clinical ExamED Clinical Exam• VS: 98 F, 90, 16, 116/63, 98% RA, 50 kgVS: 98 F, 90, 16, 116/63, 98% RA, 50 kg• The pt was alert, was able to slowly respond The pt was alert, was able to slowly respond

to simple commands. The pt had a patent to simple commands. The pt had a patent airway, no carotid bruits, clear lungs, and a airway, no carotid bruits, clear lungs, and a regular cardiac exam. PERRL. There was regular cardiac exam. PERRL. There was neglect of the R visual field. There was neglect of the R visual field. There was facial weakness of the R mouth, and R upper facial weakness of the R mouth, and R upper and lower extremity flaccid paralysis. DTRs and lower extremity flaccid paralysis. DTRs were 2/2 on the L and 0/2 on the R.were 2/2 on the L and 0/2 on the R.


Medical Legal Medical Legal Landscape Regarding Landscape Regarding

EM Stroke Patient CareEM Stroke Patient Care


Medical Legal OverviewMedical Legal Overview There exist today, over 10 years since There exist today, over 10 years since

the NINDS publication, concern and the NINDS publication, concern and controversy regarding the use of IV tPA controversy regarding the use of IV tPA in ED acute ischemic stroke patientsin ED acute ischemic stroke patients

This is due, in part, to the statements This is due, in part, to the statements made by practitioners, lawyers, and EM made by practitioners, lawyers, and EM organizationsorganizations


FERNE FeedbackFERNE Feedback ““You do not provide a balanced lecture You do not provide a balanced lecture

that includes contrary viewpoints that includes contrary viewpoints regarding tPA use…” regarding tPA use…”

In reply: “The standard of care is In reply: “The standard of care is established by the experts who are established by the experts who are willing and able to testify that tPA is an willing and able to testify that tPA is an approved therapy for the treatment of approved therapy for the treatment of acute ischemic stroke patients in the acute ischemic stroke patients in the ED…”ED…”


Medical Legal Risk Medical Legal Risk Mitigation:Mitigation:

An AssessmentAn Assessment


Risk Mitigation in EMRisk Mitigation in EM High quality care always stands out as High quality care always stands out as

such (as does low quality care)such (as does low quality care) If you act in a way that is systematic, If you act in a way that is systematic,

straightforward, and always advances straightforward, and always advances the best interests of the patient, risk is the best interests of the patient, risk is minimized for both the patient and minimized for both the patient and practitionerpractitioner


Risk Mitigation in EMRisk Mitigation in EM If the patient always is provided the best If the patient always is provided the best

chance for a good outcome based on chance for a good outcome based on your actions, risk is minimized your actions, risk is minimized regardless of the actual outcomeregardless of the actual outcome

This approach is possible with tPA use This approach is possible with tPA use in ED acute ischemic stroke patient care in ED acute ischemic stroke patient care by EM physiciansby EM physicians


Public PerceptionsPublic Perceptions Every person has an opinion about the Every person has an opinion about the

potential use of tPA in acute ischemic potential use of tPA in acute ischemic strokestroke

These people are most often not These people are most often not physicians or rocket scientistsphysicians or rocket scientists

These opinions matter, establishing the These opinions matter, establishing the standard of carestandard of care

Was proper procedure followed?Was proper procedure followed?


Challenger DisasterChallenger Disaster


Challenger DisasterChallenger Disaster A teacher watching the takeoff A teacher watching the takeoff

commented:commented: ‘‘I never once had seen icicles on the space I never once had seen icicles on the space

shuttle prior to take-off. It had never been shuttle prior to take-off. It had never been freezing the night before a launch prior to freezing the night before a launch prior to the Challenger disaster’the Challenger disaster’

Not a rocket scientist, but an opinion Not a rocket scientist, but an opinion none the less…perhaps valid, also!none the less…perhaps valid, also!


Arizona Controlled BurnArizona Controlled Burn


Arizona Controlled BurnArizona Controlled Burn When asked about the fact that the When asked about the fact that the

controlled burn went out of control and controlled burn went out of control and homes were burned, the government homes were burned, the government official stated:official stated: ‘‘These things happen…I am most These things happen…I am most

interested in knowing whether or not interested in knowing whether or not proper procedure was followed in proper procedure was followed in order to minimize the chances of this order to minimize the chances of this happening.’happening.’


TranslationTranslation Stuff happens.Stuff happens. Were things done the right way, or did Were things done the right way, or did

something happen because somebody something happen because somebody didn’t do his or her job?didn’t do his or her job?

In other words, was it fated to happen or In other words, was it fated to happen or was a mistake made?was a mistake made?

This is always the critical question when This is always the critical question when a bad outcome occurs.a bad outcome occurs.


ConclusionsConclusions What is “appropriate” is determined by What is “appropriate” is determined by

all of us who are part of this process: all of us who are part of this process: patients, families, officials, and patients, families, officials, and physiciansphysicians

Most of the legal issues are Most of the legal issues are straightforward systems issues that are straightforward systems issues that are seen and understood by those who do seen and understood by those who do not practice EMnot practice EM


RecommendationsRecommendations We, as the Emergency Medicine We, as the Emergency Medicine

specialists, must take charge, lead the specialists, must take charge, lead the process, and promote excellence in process, and promote excellence in ischemic stroke patient care ischemic stroke patient care

We must act in a way that enhances We must act in a way that enhances clinical practice, patient care, and patient clinical practice, patient care, and patient outcomes for ED ischemic stroke patientsoutcomes for ED ischemic stroke patients


The Medical RecordThe Medical Record


MR is Like a Kevlar VestMR is Like a Kevlar Vest It is your greatest source of It is your greatest source of

protectionprotection It protects you such that it It protects you such that it

must always be used must always be used wisely, as is the case with wisely, as is the case with police officerspolice officers

You often don’t know when You often don’t know when it protects youit protects you


MR is Like a Seeing DeviceMR is Like a Seeing Device You see things that can You see things that can

only be seen as you write only be seen as you write up the chartup the chart

You only know fully what You only know fully what you know and what you you know and what you must do once the record is must do once the record is completedcompleted

It promotes excellence in It promotes excellence in patient carepatient care


Specific Specific Recommendations:Recommendations: Documenting in the Documenting in the

Medical RecordMedical Record


Emergency Medicine Emergency Medicine RecommendationsRecommendations


Stroke Pt DiagnosisStroke Pt Diagnosis ‘‘The pt has symptoms that are fixed and The pt has symptoms that are fixed and

are consistent with an acute ischemic are consistent with an acute ischemic stroke’stroke’


Stroke Neurological ExamStroke Neurological Exam Document a systematic neurological Document a systematic neurological

exam, one that can be used to estimate exam, one that can be used to estimate the NIHSSthe NIHSS

Make the exam function basedMake the exam function based What is the patient able to do?What is the patient able to do?


Stroke Neurological ExamStroke Neurological Exam LOC: Somnolent, responds to tactile LOC: Somnolent, responds to tactile

stimulistimuli Vision: Noted L visual field deficitVision: Noted L visual field deficit Speech: Slurred speechSpeech: Slurred speech Receptive: Understand commandsReceptive: Understand commands CN Motor: L sided mouth droopCN Motor: L sided mouth droop Extremity Motor: L sided paralysisExtremity Motor: L sided paralysis

Pronator drift of L arm Pronator drift of L arm


Stroke Neurological ExamStroke Neurological Exam Sensory: Decreased light touch LSensory: Decreased light touch L Gag reflex: Able to control airwayGag reflex: Able to control airway Pathological reflexes: Toes down going, Pathological reflexes: Toes down going,

negative Babinski negative Babinski Neglect: L sided neglectNeglect: L sided neglect


Estimate the NIHSSEstimate the NIHSS ‘‘The approximate NIHSS was 12-18, in The approximate NIHSS was 12-18, in

the range that suggests that IV tPA may the range that suggests that IV tPA may be of benefit as was the case in the be of benefit as was the case in the NINDS clinical trial’NINDS clinical trial’


Stroke Onset TimeStroke Onset Time ‘‘The ischemic stroke onset time has The ischemic stroke onset time has

been confirmed in the following way, been confirmed in the following way, suggesting the three hour window for IV suggesting the three hour window for IV tPA has not expired’tPA has not expired’


Stroke CT InterpretationStroke CT Interpretation ‘‘The CT has been reviewed and has been The CT has been reviewed and has been

cleared by the radiologist who is aware cleared by the radiologist who is aware of the potential use of IV tPA’of the potential use of IV tPA’


Blood Pressure RxBlood Pressure Rx ‘‘The blood pressure was stabilized The blood pressure was stabilized

without extraordinary intervention and without extraordinary intervention and was consistently less than 185/110, was consistently less than 185/110, allowing for safe IV tPA use’allowing for safe IV tPA use’


IV tPA Informed ConsentIV tPA Informed Consent ‘‘The following were discussed with the The following were discussed with the

patient and family:patient and family:• With tPA, there is a 30% greater chance of a With tPA, there is a 30% greater chance of a

good outcome at 3 monthsgood outcome at 3 months• With tPA use, there is 10x greater risk of a With tPA use, there is 10x greater risk of a

symptomatic ICH (severe bleeding stroke)symptomatic ICH (severe bleeding stroke)• Mortality rates at 3 months are the same Mortality rates at 3 months are the same

regardless of tPA use, because stroke is a regardless of tPA use, because stroke is a bad diseasebad disease

• About two patients will improve for every one About two patients will improve for every one that develops a symptomatic ICH’that develops a symptomatic ICH’


IV tPA Informed ConsentIV tPA Informed Consent If you document in the medical record, If you document in the medical record,

state the specificsstate the specifics ‘‘The following individuals were part of The following individuals were part of

and consented to the decision to use IV and consented to the decision to use IV tPA’tPA’

If not, use a specific consent form with If not, use a specific consent form with the data printed on itthe data printed on it


IV tPA Risk/BenefitIV tPA Risk/Benefit ‘‘The potential risks and benefits of the The potential risks and benefits of the

use of IV tPA were discussed with the use of IV tPA were discussed with the patient and/or family and these patient and/or family and these discussions lead to the decision to treat discussions lead to the decision to treat (not to treat)(not to treat) with IV tPA’ with IV tPA’


IV tPA ContraindicationsIV tPA Contraindications ‘‘The stroke pt was not a candidate for IV The stroke pt was not a candidate for IV

tPA because the time of stroke onset tPA because the time of stroke onset was not conclusively determined’was not conclusively determined’

‘‘IV tPA was not indicated because of the IV tPA was not indicated because of the presence of AFIB and an approximate presence of AFIB and an approximate NIHSS above 20’ NIHSS above 20’

There were no specific …There were no specific …


NINDS Protocol Followed NINDS Protocol Followed ‘‘I am aware of the specifics of the NINDS I am aware of the specifics of the NINDS

protocol regarding IV tPA use and protocol regarding IV tPA use and followed the protocol in order to followed the protocol in order to maximize the likelihood of a good maximize the likelihood of a good outcome for this patient’outcome for this patient’


tPA Not Clinically IndicatedtPA Not Clinically Indicated ‘‘IV tPA was IV tPA was NCINCI in this ischemic stroke in this ischemic stroke

patient for the following reasons:patient for the following reasons: Risk/Benefit profile does not suggest Risk/Benefit profile does not suggest

improved outcome with IV tPA useimproved outcome with IV tPA use Stroke onset time unclearStroke onset time unclear Pt/Family decline usePt/Family decline use Systems in place do not favor its use’Systems in place do not favor its use’


ED Systems ED Systems RecommendationsRecommendations


Obtain the CT QuicklyObtain the CT Quickly ‘‘The ED staff and CT techs were The ED staff and CT techs were

informed that the CT for this patient had informed that the CT for this patient had to be expedited because of the potential to be expedited because of the potential use of IV tPA’use of IV tPA’


Obtain a CT Read QuicklyObtain a CT Read Quickly ‘‘The CT techs and radiologists were The CT techs and radiologists were

informed that the CT reading for this informed that the CT reading for this patient had to be expedited because of patient had to be expedited because of the potential use of IV tPA’the potential use of IV tPA’


Obtain a Directed CT ReadObtain a Directed CT Read ‘‘The CT techs and radiologists were The CT techs and radiologists were

informed that the CT reading for this informed that the CT reading for this patient was for the specific purpose of patient was for the specific purpose of determining if the potential use of IV tPA determining if the potential use of IV tPA was appropriate’was appropriate’


Obtain Consults EarlyObtain Consults Early ‘‘The neurologist was notified of the The neurologist was notified of the

potential use of IV tPA prior to obtaining potential use of IV tPA prior to obtaining the head CT so that he could be present the head CT so that he could be present in the ED at the time of the decision to in the ED at the time of the decision to administer tPA, if indicated’administer tPA, if indicated’


Document Neurologist Document Neurologist Agreement with PlanAgreement with Plan

‘‘The neurologist was fully aware of the The neurologist was fully aware of the circumstances surrounding the use of IV circumstances surrounding the use of IV tPA and fully concurred with the tPA and fully concurred with the decision by the patient, family, and decision by the patient, family, and myself’myself’

‘‘A neurologist remote was consulted via A neurologist remote was consulted via phone (or telemedicine)’phone (or telemedicine)’

‘‘No neurologist was available prior to No neurologist was available prior to the administration of tPA’the administration of tPA’


Pt, Family InteractionsPt, Family Interactions• ‘‘Risks and benefits were fully explored Risks and benefits were fully explored

with the patient and relatives, leading to with the patient and relatives, leading to the decision to use tPA’the decision to use tPA’


IV tPA Dosing, TimeIV tPA Dosing, Time• ‘Based on the clearly established time

of stroke onset and the estimated (how) pt weight, at 8:21 pm, approx 1’45” after CVA sx onset:

•Initial bolus: 5 mg slow IVP over 2 min•Infusion: 40 mg infusion over 1 hour’


Avoid Blood ThinnersAvoid Blood Thinners• Order the following:• ‘Besides ASA, no additional blood

thinners such as coumadin, heparin, or plavix should be administered to this patient because of the use of IV tPA’


ED Ischemic Stroke ED Ischemic Stroke Patient OutcomePatient Outcome


Clinical Case: CT ResultClinical Case: CT Result


Clinical Case: ED RxClinical Case: ED Rx

• CT: no low density areas or bleedCT: no low density areas or bleed• No contraindications to tPA, BP OKNo contraindications to tPA, BP OK• NIH stroke scale: approx 18-20NIH stroke scale: approx 18-20• Neurologist said OK to treatNeurologist said OK to treat• tPA administered, no complicationstPA administered, no complications


tPA AdministrationtPA Administration• tPA dosing:tPA dosing:

• 8:21 pm, 1’45” after CVA sx onset8:21 pm, 1’45” after CVA sx onset• Initial bolus: 5 mg IVP over 2 minutesInitial bolus: 5 mg IVP over 2 minutes• Follow-up infusion: 40 mg, 1 hourFollow-up infusion: 40 mg, 1 hour


Repeat Patient ExamRepeat Patient Exam• Repeat neuro exam at 90 minutes:Repeat neuro exam at 90 minutes:

• Repeat Exam: Increased speech Repeat Exam: Increased speech & use of R arm, decreased & use of R arm, decreased mouth droop & visual neglectmouth droop & visual neglect

• Repeat NIH stroke scale: Repeat NIH stroke scale: approximately 12-14approximately 12-14


Hospital Course & DispositionHospital Course & Disposition

• Hospital Course: No hemorrhage, Hospital Course: No hemorrhage, improved neurologic functionimproved neurologic function

• Disposition: Rehabilitation hospitalDisposition: Rehabilitation hospital• 3 Month Exam: Near complete use of 3 Month Exam: Near complete use of

RUE, speech & vision improved, RUE, speech & vision improved, slight slight residual gait deficitresidual gait deficit

• Able to live at home with assistanceAble to live at home with assistance


ConclusionsConclusions• The IV tPA skill set is identified, limited,

and manageable• It is possible to provide quality

emergency care with IV tPA and meet a reasonable care standard

• Identify good patient candidates• Make it happen quickly• Document the ED management


ConclusionsConclusions• Guidelines, clinical studies, and

review articles do provide guidance

• Treatment options must be individualized for each patient

• Specific strategies are defined

• It is possible to practice within a reasonable standard of care

• Pt outcomes can be optimized


ConclusionsConclusions• A high standard is achievable• The record makes this happen• Good documentation minimizes risk• Good documentation enhances

likelihood of a good outcome• Documenting the ED management is a

critical step in the Rx plan


RecommendationsRecommendations• Do it right!• Be an expert and demonstrate it by

documenting well in the record• Use IV tPA to treat ischemic stroke

patients when indicated• Know the numbers and nuances• Improve patient care and EM practice• Do so without excessive risk


[email protected] 413 7490

www.ferne.org

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Edward P. Sloan, MD, MPH, FACEP Emergency Department Neurological Patient Emergencies: Optimizing...

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